Minimum Survey Vendor Business Requirements
National Implementation of the CAHPS Survey for Accountable Care Organizations (ACOs)
Participating in Medicare Initiatives

Applicant organizations (vendor and subcontractors) must currently possess all required facilities and systems to implement the CAHPS for ACOs Survey. Subcontractors will be subject to the same requirements as the applicant vendor. Organizations that are approved to administer the CAHPS for ACOs Survey must conduct all of their CAHPS for ACOs business operations within the United States. This requirement applies to all staff and subcontractors.

Purpose: Any interested survey vendor is required to possess the following minimum business requirements to ensure that all participating survey vendors are capable of administering the CAHPS for ACOs Survey in a consistent, unbiased and competent manner. At a minimum, this includes basic quality assurance and control systems and activities to prevent disorganized, biased, or illegal data collection. 

Relevant Organizational Survey Experience
Relevant Survey Experience
  • Demonstrated experience (minimum of 3 years) in Mixed-Mode survey administration that includes mail survey administration followed by survey administration via Computer Assisted Telephone Interviewing (CATI) with non-respondents
  • Demonstrated experience (minimum of 3 years) with patient experience of care surveys, surveying vulnerable populations, and experience in a health care setting
  • Demonstrated experience (minimum of 3 years) conducting surveys of the Medicare population
  • Demonstrated experience with formatting a flat ASCII file utilizing a standardized data layout and submitting encrypted data to an external data warehouse
  • Demonstrated experience in implementing HIPAA and other data security requirements

Note: All applicant vendors must fulfill the above requirements independent of a subcontractor's experience.

Number of Years in Business
  • Minimum of 4 years
Number of Years Conducting CAHPS Surveys
  • Minimum of 3 years experience conducting CAHPS surveys of individuals; all experience is within the last 5 years
Survey Capability and Capacity
  • Project Manager with 3 years of relevant Mixed-Mode (mail survey administration followed by CATI administration with non-respondents) survey experience
  • Information Systems Specialist(s) and Computer Programmer(s)/Developer(s) with 1 year experience receiving large encrypted data files in different formats/software packages electronically from an external organization; processing survey data needed for survey administration and survey response data; preparing data files for electronic submission; and submitting data files to an external organization
  • Call Center and Mail Center Supervisor (subcontractor designee, if applicable) with minimum 1 year prior experience in role
  • Have organizational back-up schedule in place for coverage of key staff
  • Do not use volunteers to conduct any aspect of the CAHPS for ACOs Survey administration process
Facilities and Systems (all administration modes)
  • Physical facilities and electronic equipment and software to collect, process and report data securely
  • A secure commercial office/facility in which all survey activities are conducted
  • Facilities and processes to protect the confidentiality of personally identifiable information and patient response data (e.g., hard copy documents must be stored in a locked file cabinet, room, or building)
  • Systems needed to protect the confidentiality of personally identifiable information and survey data received from patients. (e.g., password protections, firewalls, data encryption software, personnel access limitation procedures, and virus and spyware protection)
  • Computers and other equipment needed for survey implementation
  • Systems and ability to receive electronic sample files containing patient-level data (the sample) needed to administer the survey
  • Electronic survey management system to track fielded surveys
  • All system resources are subject to oversight activities, including site visits to physical locations
Experience with Multiple Survey Languages

Prior experience required in conducting survey administration in both English AND at least one of the following languages:

  • Spanish
  • Cantonese
  • Mandarin
  • Korean
  • Russian
  • Vietnamese
  • Portuguese
Mixed-Mode Survey Administration Must have capability to adhere to the following Mixed-Mode survey administration requirements:
  • Mail
    • Must have capability to:
      • Verify addresses of sampled patients
      • Print professional-quality survey instruments and materials according to formatting guidelines
      • Merge and print sample name and address on personalized mail survey cover letters and print corresponding unique sample identification number and ACO provider name associated with each sampled beneficiary on the mail surveys
      • Receive and process (key entry or scanning) returned mail surveys
      • Track and identify non-respondents for follow-up mailing
      • Assign disposition codes to identify the outcome of data collection for each sampled case
  • Telephone
    • Must have the equipment, software and facilities to conduct interviews using CATI, and to monitor interviewers
    • Must have capability to:
      • Verify telephone numbers
      • Develop computer programs for electronically administering the survey
      • Schedule call backs to non-respondents at varying times of the day/week
  • Assign final disposition codes to reflect the outcome of data collection for each sampled case
  • Track cases from mail survey through telephone follow-up activities
  • Mail survey administration and telephone interviews must be conducted from the physical place of business, not from a residence or virtual office
Data Processing and File Submission Must have capability to:
  • Scan or key data from completed mail surveys
  • Develop data files and edit the data according to standard protocols
  • Follow all data reporting and data submission requirements, including verifying that data files are de-identified and contain no duplicate cases
  • Export data from the electronic data collection system into the specified ASCII format. Conduct quality checks to confirm that the data are exported correctly and that the ASCII files are formatted correctly and contain the correct data headers and data records.
  • Encrypt data files for transmission per specifications
  • Submit data electronically in the specified format (ASCII) to the CAHPS for ACOs Survey secure data warehouse
  • Work with CMS’ data warehouse contractor to resolve issues or problems with data submission or data files
Data Security
  • Execute business associate agreement with ACOs and receive annual authorization from ACOs to collect data on their behalf and submit to CMS
  • Store returned paper surveys in a secure and environmentally safe location (e.g., locked file cabinet, locked closet or room)
  • Utilize firewalls and/or other mechanisms to protect electronic files
  • Employ electronic security via implementation of access levels and passwords
  • Implement daily data back-up procedures that safeguard system data
  • Utilize required encryption protocols for transmitting data files.  Transmission of protected health information (PHI) or personal identifying information (PII) via unsecure email is prohibited.
  • Develop procedures for identifying, reporting and handling breaches of confidential data
  • Data custodian must be accountable for all data security for data collection as specified in the CMS Data Use Agreement
Data Retention
  • Retain all CAHPS for ACOs Survey-related data files, including sample information and submission files, for a minimum of 3 years
  • Develop confidentiality agreements for staff and subcontractors that include language related to HIPAA regulations, and obtain signatures from all personnel with access to survey information (including staff and all subcontractors) or involved in survey administration and data collection
    • Confidentiality agreements must be reviewed and re-signed periodically, at the discretion of the survey vendor, but not to exceed more than a three-year period
  • Monitor staff and subcontractors to ensure compliance with HIPAA regulations in regards to PHI and PII
  • Ensure Data Use Agreement (DUA) with CMS is kept up to date and that all DUA requirements are followed, including cell size suppression rules
  • Store CAHPS for ACOs Survey data files (paper or electronic) securely and confidentially in accordance with requirements specified in the Quality Assurance Guidelines. Archived electronic data files must be easily retrievable.
Customer Support
  • Provide toll-free customer support telephone lines with live operator during regular business hours (to be established from the date of the pre-notification letter through the end of data collection)

    • Customer support must be offered in all languages survey vendor contracted to provide for survey administration.
    • Respond to calls within 24-48 hours
Adherence to Quality Assurance Guidelines and Participation in QA Activities
Demonstrated Quality Control Procedures
  • Demonstrated ability to conduct well-documented quality control procedures (as applicable) for:
    • In-house training of staff involved in survey operations
      • Printing, mailing and recording of receipt of mail surveys
    • Telephone administration of survey (CATI system)
      • Coding and editing of survey data and survey-related materials
    • Scanning or keying in survey data
    • Preparing final record-level data files for submission
    • All other functions and processes that impact the administration of the CAHPS for ACOs Survey
  • Participate in conference calls and site visits as scheduled by the Project Team as part of mandatory quality oversight activities
  • Develop and submit annual Quality Assurance Plans by specified due date
Documentation Requirements
Maintain Records

Must provide documentation as requested for site visits and conference calls, including but not limited to: HIPAA compliance, mail material production, staff training records, telephone interviewer monitoring records, and file construction documentation.

  • Maintain records to document staff have been monitored for compliance with HIPAA regulations
  • Maintain documentation related to mail production activities, including quality checklists and seeded mail logs
  • Keep electronic or hard copy files of staff training and dates
  • Maintain electronic or hard copy records of interviewer monitoring activities
  • Maintain electronic or hard copy records of survey mailing dates and dates of returned surveys
  • Maintain other documentation necessary to allow the CAHPS for ACOs Survey Project Team to review survey protocol implementation during site visits
  • Maintain documentation of actions required (and implemented) as a result of site visit findings by the Project Team
Adhere to all Protocols and Specifications, and Agree to Participate in Training Sessions
Survey Training
  • Attend and successfully complete all CAHPS for ACOs Survey Training Sessions
    • At a minimum, vendor and subcontractor organizations staff fulfilling the following functional roles must attend training:
      • Project Manager
      • Mail Center Supervisor
      • Call Center Supervisor
      • Sample, CATI and Data Support:
        • Decrypting the sample file and performing sample file quality checks
        • Programming the CATI script
        • Preparing and submitting the survey data file
  • Pass a post-training quiz measuring comprehension of CAHPS for ACOs Survey protocols
  • Participate in additional CAHPS for ACOs Training Sessions
Vendor Approval Term
  • Vendor organization is approved for 1 year subject to annual re-approval
  • Approved survey vendors are required to maintain at least one active CAHPS for ACOs Survey client contract for at least one of two consecutive survey administration cycles. 
Administer the Survey According to All Survey Specifications
  • Must review and follow all procedures described in the CAHPS Survey for ACOs Participating in Medicare Initiatives Quality Assurance Guidelines Version 7
  • Must agree to all conditions in the Vendor Participation Application


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